Both Medicare and Medicaid have national “medically unlikely edits” (MUEs) in place that are designed to automatically deny claims that exceed specific daily limits. Although these MUEs have been in place for some time, some Medicaid plans are only now beginning to implement them. MUEs should not be confused with annual utilization limits that we have seen from many commercial payers.
For many years, the MUEs were confidential and were not published. But a couple of years ago, CMS decided they should be made publically available. Although we have published them before and they have not changed, we thought this would be a good time for a reminder.
| Code | Description | Medicare and Medicaid MUE |
|---|---|---|
| 95004 | Subcutaneous skin tests/allergenic extracts | 80 |
| 95012 | Expired Nitric Oxide | 2 |
| 95017 | Venom skin testing | 27 |
| 95018 | Skin testing for drugs and biologicals | 19 |
| 95024 | Intracutaneous tests/allergenic extracts | 40 |
| 95027 | Intracutaneous sequential and incremental | 90 |
| 95028 | Intracutaneous/allergenic extracts/delayed reaction | 30 |
| 95044 | Patch test | 80 |
| 95076 | Ingestion challenge/initial 120 minutes | 1 |
| 95079 | Ingestion challenge/each additional hour | 2 |
| 95144 | Allergy immunotherapy /single dose vials | 30 |
| 95145 | Venom immunotherapy/1 venom | 10 |
| 95146 | Venom immunotherapy/2 venoms | 10 |
| 95147 | Venom immunotherapy/3 venoms | 10 |
| 95148 | Venom immunotherapy/4 venoms | 10 |
| 95149 | Venom immunotherapy/5 venoms | 10 |
| 95165 | Allergen immunotherapy/multi-dose vials | 30 |
| 95170 | Allergen immunotherapy/whole body extract | 10 |
| 95180 | Rapid desensitization/each hour | 6 |
For example, if you bill Medicare or Medicaid for more than 80 skin tests on a given day, you may receive a denial. Likewise, a claim with more than 30 doses of allergen immunotherapy (95165) may also trigger a denial. You may want to be aware of these limits when billing Medicare and Medicaid.
It is also important to remember that, for payment purposes, Medicare defines a dose of allergen immunotherapy as one cc of extract. Because Medicaid is a state program, policies vary from state to state. If your state Medicaid plan adopts the same policy on definition of a dose as Medicare, the Advocacy Council may be able to provide guidance for a discussion with Medicaid payers.
For more information on CPT 95165, join our webinar – Everything you wanted to know about 95165 – on Feb. 20 at 7:30 pm CT.
